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Complexity, Not Severity: Reinterpreting the Sliding Scale of Capacity

Published online by Cambridge University Press:  18 November 2022

George Mellgard  and
Nada Gligorov
George Mellgard
Affiliation:
Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
Nada Gligorov*
Affiliation:
Alden March Bioethics Institute, Albany Medical College, Albany, New York 12208, USA
*
*Corresponding author. Email: [email protected]
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Abstract

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary. We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision should be identified based on a patient’s particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making.

Keywords

capacitydementiacognitive complexitysliding scalemedical decisionscognitive deficits
Type
Research Article
Information
Cambridge Quarterly of Healthcare Ethics , Volume 31 , Issue 4 , October 2022 , pp. 506 - 517
Copyright
© The Author(s), 2022. Published by Cambridge University Press

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References

Notes

1. Favreault, MM, Gleckman, H, Johnson, RW. Financing long-term services and supports: Options reflect trade-offs for older Americans and federal spending. Health Affairs 2015;34(12):2181–91CrossRefGoogle ScholarPubMed.

2. Christina, P. World Alzheimer’s report 2018. In: Alzheimer’s Disease International: World Alzheimer Report. London: Alzheimer’s Disease International; 2018:1–48 Google Scholar.

3. Sessums, LL, Zembrzuska, H, Jackson, JL. Does this patient have medical decision-making capacity? JAMA 2011;306(4):420–7CrossRefGoogle ScholarPubMed.

4. Appelbaum, PS. Assessment of patients’ competence to consent to treatment. New England Journal of Medicine 2007;357(18):1834–40CrossRefGoogle ScholarPubMed.

5. Beauchamp, TL. The right to die as the triumph of autonomy. Journal of Medicine and Philosophy 2006;31(6):643–54CrossRefGoogle ScholarPubMed.

6. Hermann, H, Trachsel, M, Biller-Andorno, N. Physicians’ personal values in determining medical decision-making capacity: A survey study. Journal of Medical Ethics 2015;41(9):739–44CrossRefGoogle ScholarPubMed.

7. Appelbaum, PS, Grisso, T. The MacArthur treatment competence study. I: Mental illness and competence to consent to treatment. Law and Human Behavior 1995;19(2):105–26CrossRefGoogle Scholar.

8. Dunn, LB, Nowrangi, MA, Palmer, BW, Jeste, DV, Saks, ER. Assessing decisional capacity for clinical research or treatment: A review of instruments. American Journal of Psychiatry 2006;163(8):1323–34CrossRefGoogle ScholarPubMed.

9. Edelstein B. Hopemont Capacity Assessment Interview Manual and Scoring Guide. Morgantown, WV: West Virginia University; 1999.

10. Marson, DC, Ingram, KK, Cody, HA, Harrell, LE. Assessing the competency of patients with Alzheimer’s disease under different legal standards: A prototype instrument. Archives of Neurology 1995;52(10):949–54CrossRefGoogle ScholarPubMed.

11. Appelbaum, PS, Grisso, T. Assessing patients’ capacities to consent to treatment. New England Journal of Medicine 1988;319(25):1635–8CrossRefGoogle ScholarPubMed.

12. See note 4, Appelbaum 2007, at 1834–40.

13. Marson, DC, McInturff, B, Hawkins, L, Bartolucci, A, Harrell, LE. Consistency of physician judgments of capacity to consent in mild Alzheimer’s disease. Journal of the American Geriatrics Society 1997;45(4):453–7CrossRefGoogle ScholarPubMed.

14. Moye, J, Karel, MJ, Azar, AR, Gurrera, RJ. Capacity to consent to treatment: Empirical comparison of three instruments in older adults with and without dementia. The Gerontologist 2004;44(2):166–75CrossRefGoogle ScholarPubMed.

15. Trachsel, M, Hermann, H, Biller-Andorno, N. Cognitive fluctuations as a challenge for the assessment of decision-making capacity in patients with dementia. American Journal of Alzheimer’s Disease & Other Dementias 2015;30(4):360–3CrossRefGoogle ScholarPubMed.

16. Huthwaite, J, Martin, R, Griffith, H, Anderson, B, Harrell, L, Marson, D. Declining medical decision-making capacity in mild Alzheimer’s disease: A two-year longitudinal study. Behavioral Sciences and the Law 2006;24(4):453–63CrossRefGoogle ScholarPubMed.

17. See note 16, Huthwaite et al. 2006, at 453–63.

18. Fellows, LK. Competency and consent in dementia. Journal of the American Geriatrics Society 1998;46(7):922–6CrossRefGoogle ScholarPubMed.

19. Marson, DC, Hawkins, L, McInturff, B, Harrell, LE. Cognitive models that predict physician judgments of capacity to consent in mild Alzheimer’s disease. Journal of the American Geriatrics Society 1997;45(4):458–64CrossRefGoogle ScholarPubMed.

20. Goodman, RA, Lochner, KA, Thambisetty, M, Wingo, TS, Posner, SF, Ling, SM. Prevalence of dementia subtypes in United States medicare fee-for-service beneficiaries, 2011–2013. Alzheimer’s & Dementia 2017;13(1):28–37 CrossRefGoogle ScholarPubMed.

21. Román GC. Clinical forms of vascular dementia. In: Paul, R.H., Cohen, R., Ott, B.R., Salloway, S. (eds) Vascular Dementia. Current Clinical Neurology. Humana Press. 2005:7–21.

22. Metzler-Baddeley, C. A review of cognitive impairments in dementia with Lewy bodies relative to Alzheimer’s disease and Parkinson’s disease with dementia. Cortex 2007;43(5):583–600 CrossRefGoogle ScholarPubMed.

23. Manes, F, Torralva, T, Ibáñez, A, Roca, M, Bekinschtein, T, Gleichgerrcht, E. Decision-making in frontotemporal dementia: Clinical, theoretical and legal implications. Dementia and Geriatric Cognitive Disorders 2011;32(1):11–7CrossRefGoogle ScholarPubMed.

24. See note 15, Trachsel et al. 2015, at 360–3.

25. Escandon, A, Al-Hammadi, N, Galvin, JE. Effect of cognitive fluctuation on neuropsychological performance in aging and dementia. Neurology 2010;74(3):210–7CrossRefGoogle ScholarPubMed.

26. Walker, M, Ayre, G, Cummings, J, Wesnes, K, McKeith, I, O’brien, J, et al. Quantifying fluctuation in dementia with Lewy bodies, Alzheimer’s disease, and vascular dementia. Neurology 2000;54(8):1616–25Google ScholarPubMed.

27. See note 25, Escandon et al. 2010, at 210–7.

28. See note 15, Trachsel et al. 2015, at 360–3.

29. See note 26, Walker et al. 2000, at 1616–25.

30. Lee, DR, McKeith, I, Mosimann, U, Ghosh-Nodial, A, Grayson, L, Wilson, B, et al. The dementia cognitive fluctuation scale, a new psychometric test for clinicians to identify cognitive fluctuations in people with dementia. The American Journal of Geriatric Psychiatry 2014;22(9):926–35CrossRefGoogle Scholar.

31. Marson D, Harrell L. Neurocognitive changes associated with loss of capacity to consent to medical treatment in patients with Alzheimer’s disease. In: Morrell RW, Shifren K, Park D, Park D, eds. Processing of Medical information in Aging Patients: Cognitive and Human Factors Perspectives. 1st ed. Lawrence Erlbaum Associates Publishers; 1999:109–26.

32. See note 31, Marson, Harrell 1999, at 109–26.

33. Moye, J, Karel, MJ, Gurrera, RJ, Azar, AR. Neuropsychological predictors of decision-making capacity over 9 months in mild-to-moderate dementia. Journal of General Internal Medicine 2006;21(1):78–83 CrossRefGoogle ScholarPubMed.

34. Kim, SY, Karlawish, JH, Caine, ED. Current state of research on decision-making competence of cognitively impaired elderly persons. The American Journal of Geriatric Psychiatry 2002;10(2):151–65CrossRefGoogle ScholarPubMed.

35. Gurrera, R, Moye, J, Karel, M, Azar, A, Armesto, J. Cognitive performance predicts treatment decisional abilities in mild to moderate dementia. Neurology 2006;66(9):1367–72CrossRefGoogle ScholarPubMed.

36. See note 33, Moye et al. 2006, at 78–83.

37. Okonkwo, O, Griffith, H, Belue, K, Lanza, S, Zamrini, E, Harrell, L, et al. Medical decision-making capacity in patients with mild cognitive impairment. Neurology 2007;69(15):1528–35CrossRefGoogle ScholarPubMed.

38. See note 16, Huthwaite et al. 2006, at 453–63.

39. Appelbaum, PS. Consent in impaired populations. Current Neurology and Neuroscience Reports 2010;10(5):367–73CrossRefGoogle ScholarPubMed.

40. United States. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. U S Code Annot U. S. 1982; Title 42 Sect. 300v as added 1978.

41. Drane, JF. Competency to give an informed consent: A model for making clinical assessments. JAMA 1984;252(7):925–7CrossRefGoogle Scholar.

42. Drane, JF. The many faces of competency. Hastings Center Report 1985;15:17–21 CrossRefGoogle ScholarPubMed.

43. Kim, SY, Caine, ED, Swan, JG, Appelbaum, PS. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics 2006;47(4):325–9CrossRefGoogle ScholarPubMed.

44. See note 43, Kim et al. 2006, at 325–9.

45. See note 41, Drane 1984, at 925–7.

46. See note 35, Gurrera et al. 2006, at 1367–72.

47. Saks, ER, Jeste, DV. Capacity to consent to or refuse treatment and/or research: Theoretical considerations. Behavioral Sciences & The Law 2006;24(4):411–29CrossRefGoogle ScholarPubMed.

48. Kim, SY, Karlawish, JH, Kim, HM, Wall, IF, Bozoki, AC, Appelbaum, PS. Preservation of the capacity to appoint a proxy decision maker: Implications for dementia research. Archives of General Psychiatry 2011;68(2):214–9CrossRefGoogle ScholarPubMed.

49. See note 48, Kim et al. 2011, at 214–9.

50. Bester, J, Cole, CM, Kodish, E. The limits of informed consent for an overwhelmed patient: Clinicians’ role in protecting patients and preventing overwhelm. AMA Journal of Ethics 2016;18(9):869–86Google ScholarPubMed.

51. See note 48, Kim et al. 2011, at 214–9.

52. See note 34, Kim et al. 2002, at 151–65.

53. See note 50, Bester et al. 2016, at 869–86.

54. Buchanan, AE, Brock, DW. The Ethics of Surrogate Decision Making. New York: Cambridge University Press; 1989 Google Scholar.

55. Culver, CM, Gert, B. The inadequacy of incompetence. The Milbank Quarterly 1990;68:619–43CrossRefGoogle ScholarPubMed.

56. See note 48, Kim et al. 2011, at 214–9.

57. See note 55, Culver, Gert 1990, at 619–43.

58. See note 55, Culver, Gert 1990, at 619–43.

59. Moye, J, Butz, SW, Marson, DC, Wood, E. A conceptual model and assessment template for capacity evaluation in adult guardianship. The Gerontologist 2007;47(5):591–603 CrossRefGoogle ScholarPubMed.

60. See note 33, Moye et al. 2006, at 78–83.

61. See note 35, Gurrera et al. 2006, at 1367–72.

62. See note 59, Moye et al. 2007, at 591–603.

63. Fox, C, Smith, T, Maidment, I, Hebding, J, Madzima, T, Cheater, F, et al. The importance of detecting and managing comorbidities in people with dementia? Age and Ageing 2014;43(6):741–3CrossRefGoogle ScholarPubMed.

64. Song, M-K, Ward, SE, Hepburn, K, Paul, S, Kim, H, Shah, RC, et al. Can persons with dementia meaningfully participate in advance care planning discussions? A mixed-methods study of SPIRIT. Journal of Palliative Medicine 2019;22(11):1410–6CrossRefGoogle ScholarPubMed.

65. See note 33, Moye et al. 2006, at 78–83.

66. Moye, J, Gurrera, RJ, Karel, MJ, Edelstein, B, O’Connell, C. Empirical advances in the assessment of the capacity to consent to medical treatment: Clinical implications and research needs. Clinical Psychology Review 2006;26(8):1054–77CrossRefGoogle ScholarPubMed.

67. See note 14, Moye et al. 2004, at 166–75.

68. See note 11, Appelbaum, Grisso 1988, at 1635–8.

69. See note 66, Moye et al. 2006, at 1054–77.

70. See note 33, Moye et al. 2006, at 78–83.

71. Rosenstein, DL, Miller, FG. Research Involving those at Risk for Impaired Decision-Making Capacity. New York: Oxford University Press; 2008 Google Scholar.

72. See note 37, Okonkwo et al. 2007, at 1528–35.

73. See note 16, Huthwaite et al. 2006, at 453–63.

74. See note 66, Moye et al. 2006, at 1054–77.

75. See note 11, Appelbaum, Grisso 1988, at 1635–8.